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Insurance claim appeal.

I started to send this letter "To Whom It May Concern" but was afraid that it might be returned to me with a stamp that reads "No Such Person At This Address." Please consider this correspondence an official appeal to your decision to deny payment of our claim for our daughter, Ashley Ann. The amount of $587.20 was paid to a local adaptive equipment dealer for an insert that is an integral part of Ashley's wheelchair, stroller, whatever you want to call it.

If at all possible, please try to step back from your spreadsheets and printouts and try to see the human side of our story. The following is a brief history of events that have occurred thus far:

1. We submitted the claim for Ashley's seat insert to your company, our insurer.

2. Around Christmas, our adaptive equipment dealer received a letter from your company stating that they needed more information about the insert before the claim would be processed.

3. We received a letter from your company, our insurer, stating that the claim could not be processed because your company was waiting on further information from our adaptive equipment dealer. My wife, Kristi, called your company to follow up and was informed that no correspondence from our adaptive equipment dealer had been received. We were reasonably certain that this correspondence had been sent to your company since we had a copy of the letter from our adaptive equipment dealer. But, we obliged your request and asked the adaptive equipment dealer to resubmit their information.

4. In February, approximately two or three days after Kristi called your company and found that our adaptive equipment dealer's letter was not on file, Kristi called your company again to let you know that a second copy of the letter should be en route. In this conversation, Kristi was told by your company's representative that, "Oh, yes, we have that letter. Your claim has been denied." Pretty fast work. The representative went on to tell Kristi that we would have to appeal this decision if we wanted to pursue the matter further. Kristi asked how the appeals process works. The representative told Kristi that she did not know. (This was the Customer Service department. Keep this in mind for further reference.) The representative went on to say that she would have Someone get back to her. (I'm sure you're familiar with Someone. Someone has been on your payroll for years. Someone is the person that is always going to do something Someday.)

Well, Someone never got back to us with the steps to the appeals process. In fact, Kristi made the same request for Someone to return her call on at least three other occasions. No call. Returning telephone calls is a basic business courtesy -- much like submitting claims without using those ghastly, insidious staples or the timely payment of premiums.

5. Finally, Kristi was able to talk to Dawn to try to get some information. Dawn said that the claim for the insert had been denied in error and a check would be processed in the next 10 days. She went on to say that the reason the payment would be made was because we had been assigned to Medical Case Management. Well, this was news to us. We have experience with Medical Case Management because my employer's previous insurance carrier placed us on their MCM program. We received phone calls at least two or three times a week from the nurse that was assigned to us, and the results were actually very good. When my employer began coverage with your company, I spoke with a representative early in our relationship and asked if the Medical Case Management would continue. The representative told me that your company's strategy would be to "wait and see what happens, and I'll have Someone contact you if Medical Case Management becomes necessary."

Well, Sometime, Someone placed us on Medical Case Management, but as usual, Someone never contacted us. Kristi learned during her telephone conversation with Dawn that being on Medical Case Management entitled us to an extended number of therapy visits. I suspect that the reason this fact was not communicated to us was simple: "If the Whitlows know that (more visits) are available, they will probably go to the therapist more often." Well, let me tell you, you've got me there. Nothing gives me more pleasure than taking the time to bring Ashley to the therapist, and the ever-popular fitting for braces. What a thrill

What you people don't seem to understand is that this therapy (and the seat insert, I might add) is necessary to maintain Ashley's circulation and help her remain upright, which will assist her in fighting respiratory problems and organ failure later on. This will result in lower medical bills in the future (and extend her quality of life and life span also). But, I realize this is not a concern of yours.

6. In March, Dawn called Kristi at home to explain that she had made a mistake. The information had been sent down to "the nurse" who ruled that this insert was not "medically necessary."

Kristi asked if she could speak to the nurse concerning the rationale, if any, behind her decision. Kristi was told that it would not be possible for her to speak to the nurse because, "If we let customers speak to the nurses, they would never have time to get their work done." This approach is too obtuse for words. I'll not labor this point any further.

Well, Kristi asked about the qualifications of this faceless, mute and nameless nurse (who is, no doubt, blood kin to Someone). Dawn told Kristi that "all of the nurses are equally qualified." This declaration is not exactly a source of comfort.

I'll tell you what: Go to your local hospital and visit the neonatal ICU, cancer and burn wards and find out for yourself how equally qualified the nurses are. I do not question their skills, but their level of expertise drops outside their areas of specialty.

At this point in the conversation, Dawn asked Kristi if she would like to talk to a supervisor. Kristi said that she would. The supervisor restated that the claim would be denied because the insert is not medically necessary. It was apparent that the buck would have to be put on hold here.

Kristi asked why we had not been notified that we had been placed on Medical Case Management. The supervisor's response was, "All we can do here is apologize." This statement is probably closer to the truth than anything else we have heard from your company.

The basis for our appeal is this:

* The seat insert is medically necessary. The information you received from our adaptive equipment dealer (if you read it) indicated this fact.

* The seat insert is consistent with other equipment that you have paid for in the past (i.e. braces, IFO's, etc.). Try to read this letter flat on your back without the use of your arms and think again about what is medically necessary.

If you need more information processing this appeal, please have a person with a name contact me promptly. Please do not have Someone call me.

Even if this claim remains denied, I think you have a larger service issue that needs to be addressed. Successful companies all over the world are finding that their success depends on quality Customer Service. From all appearances, you have not jumped on the bandwagon. Basic business practices such as job knowledge, truth and follow-through seem to have fallen through the cracks.

If your company does not learn to conduct its business in a professional, efficient manner, you will not survive. You will find me shedding no tears. Take a look around, though. I'm sure Someone will be to blame.

Ryan d. Whitlow lives in Oklahoma City, Okla., with his wife, Kristi, and daughters Leslie, 9, and Ashley, 6. He is a training specialist for Scrivner, Inc., a wholesale grocery company.

Whitlow's insurance claim appeal letter was submitted to Exceptional Parent by Ashley's physical therapist, Mary Deaton-Pickett. She wrote "(The Whitlows) had been in a several month battle with their insurance company regarding payment for an adaptive seat insert for Ashley's wheelchair. l was so impressed with this letter (because it) expresses Mr. Whitlow's anger and frustration, but also shows his determination not to give up as well as the most important thing -- a sense of humor, (which is) imperative for our families to survive. I hope you see the universal nature of (a situation) that many families have to endure."
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Title Annotation:Annual Mobility Guide for Parents of Children and Adolescents, 1993
Author:Whitlow, Ryan J.
Publication:The Exceptional Parent
Article Type:Directory
Date:Mar 1, 1993
Previous Article:Agencies and organizations.
Next Article:Baby girl.

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